Provider Demographics
NPI:1124176896
Name:CAROLINA FAMILY PSYCHIATRY, LLC
Entity type:Organization
Organization Name:CAROLINA FAMILY PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRODERICK-CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-971-9495
Mailing Address - Street 1:300 W COLEMAN BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3429
Mailing Address - Country:US
Mailing Address - Phone:843-971-9495
Mailing Address - Fax:843-971-9697
Practice Address - Street 1:300 W COLEMAN BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3429
Practice Address - Country:US
Practice Address - Phone:843-971-9495
Practice Address - Fax:843-971-9697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC289032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC28903OtherSTATE LICENSE
SC28903OtherSTATE LICENSE